Understanding a Complex Medical Case: When Back Pain and Fatigue Reveal Hidden Cancer

Table of Contents

• Case Presentation: A 65-Year-Old Woman's Symptoms
• Medical History and Risk Factors
• Initial Examination and Laboratory Findings
• Differential Diagnosis: Considering All Possibilities
• Diagnostic Process and Imaging Results
• Final Diagnosis and Explanation
• Clinical Implications for Patients
• Limitations of This Case Study
• Patient Recommendations and Takeaways
• Source Information

Case Presentation: A 65-Year-Old Woman's Symptoms

A 65-year-old woman was transferred to Massachusetts General Hospital for evaluation of pancytopenia (dangerously low levels of all blood cells) and severe back pain. Her symptoms began three weeks earlier when she developed midline cervical, thoracic, and lumbar back pain after rolling a patient over during her work as a home health aide.

Initially, her neurological examination showed preserved strength, normal gait, and no spinal tenderness. She was treated with prednisone, tramadol, and cyclobenzaprine along with physical therapy, but her pain persisted. Spinal radiographs showed only diffuse osteopenia (reduced bone density) and moderate degenerative disk disease without acute fracture.

Four days before transfer, her sister found her lying on the floor of her home, immobilized by back pain. She was taken to another hospital's emergency department where critical laboratory abnormalities were discovered: platelet count of 14,000 per microliter (normal: 150,000-450,000), hemoglobin level of 8.9 g/dL (normal: 12.0-16.0), and white cell count of 5,100 per microliter (normal: 4,500-11,000). Her blood smear showed immature granulocytes and nucleated red cells - both abnormal findings indicating bone marrow stress.

Medical History and Risk Factors

The patient had a significant medical history including primary hypothyroidism, type 2 diabetes, migraines, and a known intraductal papillary mucinous neoplasm (a type of pancreatic cyst). She had undergone sigmoid colectomy and partial small-bowel resection for complicated diverticulitis, plus hysterectomy and cholecystectomy in the past.

Her medications included escitalopram, topiramate, levothyroxine, and pancreatic enzyme-replacement therapy. Critically, she had an 80-pack-year smoking history (smoking two packs daily for 40 years), though she had quit three years earlier. She had no alcohol or recreational drug use.

Her family history was notable for breast cancer in her mother (diagnosed at age 70) and colorectal cancer in her niece (diagnosed at age 40). She had undergone colonoscopy 18 months prior that showed hyperplastic polyps and tubular adenomas that were resected, and a normal mammogram five years earlier.

Initial Examination and Laboratory Findings

On admission to Massachusetts General Hospital, her vital signs showed temperature of 36.2°C, heart rate of 89 beats per minute, respiratory rate of 16 breaths per minute, blood pressure of 167/71 mm Hg, and oxygen saturation of 95% on room air. She appeared pale and tired with epigastric tenderness but no ecchymoses or petechiae (bruising or small bleeding spots under the skin).

Her blood counts had worsened: platelet count dropped to 10,000 per microliter, hemoglobin to 7.5 g/dL, and white cell count to 2,860 per microliter. Manual differential count showed 9.4% nucleated red cells (normal: 0%), 1.0% plasma cells (normal: 0%), and 1.0% metamyelocytes (normal: 0%). The reticulocyte count was 1.9% (normal: 0.7-2.5%).

Additional abnormal laboratory findings included:

• Lactate dehydrogenase level greater than 2500 U/L (normal: 110-210)
• Ferritin level 24,325 μg/L (normal: 10-200)
• Haptoglobin level 91 mg/dL (normal: 30-200)
• Aspartate aminotransferase 102 U/L (normal: 9-32)
• Alanine aminotransferase 64 U/L (normal: 7-33)
• Alkaline phosphatase 308 U/L (normal: 45-115)
• Lipase greater than 3000 U/L (normal: 13-60)

Peripheral blood smear showed basophilic stippling, hypolobated neutrophils with prominent granules, and thrombocytopenia with occasional large platelets. No blasts or schistocytes (fragmented red blood cells) were seen.

Differential Diagnosis: Considering All Possibilities

Doctors considered an extensive list of possible causes for her pancytopenia, organized into several categories:

Nutritional Deficiencies: Vitamin B12 and folate deficiencies can cause megaloblastic anemia with pancytopenia, but her levels were normal. Copper deficiency was also ruled out with normal copper levels.

Toxins: Medications, alcohol, or other toxins can cause bone marrow suppression, but she wasn't taking any medications typically associated with pancytopenia and had no significant alcohol use.

Infections: Various viral infections (Epstein-Barr virus, cytomegalovirus, HIV, viral hepatitis) can cause pancytopenia, but extensive testing for these and tick-borne diseases was negative.

Autoimmune Conditions: Autoimmune diseases can cause cytopenias through various mechanisms, but she lacked typical systemic manifestations aside from her markedly elevated ferritin suggesting inflammation.

Thrombotic Microangiopathy: This includes conditions like thrombotic thrombocytopenic purpura (TTP) where small blood clots form throughout the body, destroying red blood cells and platelets. She was initially transferred for TTP evaluation, but the absence of schistocytes on repeat blood smear made this less likely.

Primary Hematologic Cancers: Leukemias or lymphomas can disrupt normal blood cell production, but her presentation wasn't typical for these conditions.

Myelophthisis: This refers to bone marrow invasion and replacement by non-blood cells, typically from metastatic cancer. Her peripheral blood showing nucleated red cells, weight loss, bone pain, and smoking history made this a strong consideration.

Diagnostic Process and Imaging Results

CT imaging of the chest revealed several concerning findings:

• Supraclavicular, mediastinal, and hilar lymphadenopathy with enlarged lymph nodes up to 26 mm
• An 11 mm lobulated, solid nodule in the right middle lobe
• Nodular interlobular septal thickening and ground-glass opacities in the right upper lobe

Given these findings and her deteriorating condition, doctors performed a bone marrow biopsy to look for evidence of cancer infiltration.

Final Diagnosis and Explanation

The bone marrow biopsy revealed extensive infiltration by atypical cells with speckled chromatin, nuclear molding, and areas of necrosis. Immunohistochemical staining showed these cells were positive for CD56 and synaptophysin - markers indicating neuroendocrine differentiation.

The final diagnosis was bone marrow infiltration by metastatic neuroendocrine carcinoma with cancer-associated thrombotic microangiopathy. This means an aggressive neuroendocrine cancer (likely originating from the lung given her extensive smoking history) had spread to her bone marrow, disrupting normal blood cell production and causing the destructive changes throughout her body.

Cancer-associated thrombotic microangiopathy occurs when tumor cells disrupt small blood vessels, causing red blood cell fragmentation, platelet consumption, and tissue damage. This explained her combination of pancytopenia, elevated lactate dehydrogenase, and other laboratory abnormalities.

Clinical Implications for Patients

This case illustrates several important clinical points for patients:

First, seemingly routine symptoms like back pain and fatigue can sometimes signal serious underlying conditions, especially when they persist despite appropriate treatment or are accompanied by other concerning symptoms like weight loss or night sweats.

Second, a comprehensive history including smoking history, family cancer history, and complete medication review is crucial for proper diagnosis. Her 80-pack-year smoking history was a critical clue pointing toward lung cancer.

Third, pancytopenia (low blood counts across all cell types) requires thorough evaluation because it can indicate bone marrow infiltration by cancer, even when obvious tumor masses aren't immediately visible on imaging.

Finally, cancer-associated thrombotic microangiopathy is a rare but serious complication of advanced cancers that can mimic other blood disorders. Early recognition is important because treatment must address the underlying cancer rather than just the blood abnormalities.

Limitations of This Case Study

While this case provides valuable insights, it's important to recognize its limitations as a single case report:

The presentation described represents an unusual and severe manifestation of cancer. Most patients with back pain or fatigue do not have underlying cancer, and most cancers do not present with such dramatic blood abnormalities.

The patient had multiple risk factors (extensive smoking history, previous abdominal surgeries, family cancer history) that may not apply to other patients with similar symptoms.

As a case report, this represents clinical experience rather than systematic research. The findings shouldn't be generalized to all patients without consideration of individual circumstances.

The diagnostic process described occurred at a major academic medical center with extensive resources. Community hospitals might approach similar cases differently based on available expertise and testing capabilities.

Patient Recommendations and Takeaways

Based on this case, patients should:

1. Report persistent symptoms that don't improve with initial treatment, especially when accompanied by weight loss, night sweats, or excessive fatigue
2. Provide complete medical histories including smoking history, family cancer history, and all medications and supplements
3. Follow recommended cancer screenings based on age, gender, and risk factors
4. Seek prompt evaluation for concerning symptoms like easy bruising, bleeding, or severe unexplained fatigue
5. Understand that comprehensive evaluation sometimes requires multiple tests to identify rare or unusual conditions

For patients with similar presentations, this case emphasizes that thorough evaluation including bone marrow examination may be necessary when blood abnormalities persist without clear explanation, particularly when there are risk factors for cancer.

Source Information

Original Article Title: Case 7-2025: A 65-Year-Old Woman with Weakness, Back Pain, and Pancytopenia

Authors: Rebecca K. Leaf, MD; Brandon H. Messick, DO; Catherine B. Meador, MD, PhD; Derek Loneman, MD

Publication: The New England Journal of Medicine, February 27, 2025; 392:903-914

DOI: 10.1056/NEJMcpc2412515

This patient-friendly article is based on peer-reviewed research from The New England Journal of Medicine. It preserves all significant medical findings, laboratory values, and clinical details from the original case report while making the information accessible to educated patients.